Frimley Park Hospital has reviewed its process for assessing patients who could be at risk of a fall after an elderly man died in its care.
Thomas Petto, 81, from Farnborough, died on August 24 last year at the hospital.
The retired aircraft engineer manager was admitted on June 30 as he had been feeling generally unwell.
His son, Martin, visited every day and staff told him his father had fallen in the hospital on a number of occasions.
At an inquest into Mr Petto’s death held at Woking Coroner’s Court last week, a statement from his son said: “My parents had been married since 1958 and my mother passed away in 2010, and since then he lived on his own.
“He did not have many friends and became lonely when my mother passed away.
“I know he had problems with his bowel and had prostate cancer.
“Towards the end of his life he did have a couple of falls, but he would not have anyone come to help him.”
Mr Petto Snr fell again last August 23. His son put him in a wheelchair and took him to the front of the hospital and arranged to see him the next day.
He later received a call around midnight informing him that his father was passing away, and he was asked to go back to the hospital.
Giving evidence at the inquest, Martin Petto said of his father: “He had a couple of falls at home, they were the only falls he had that I knew of, and it was because of that, because of his weakness, that I decided to call the ambulance.”
Bleeding from the ear
Hospital staff said Mr Petto fell on around three occasions, but after speaking to his father it became apparent to Martin Petto that he had had around seven falls.
He said: “He was never one to complain, he was an old-fashioned type of man.”
Nicola Ranger, director of nursing at Frimley Park, said the hospital had since changed the way that patients at risk of falling are assessed.
She said: “We feel that we get quite a frail population coming to hospital and it’s trying to work out who is a high risk of having falls. We are now trying to have a more visual picture.”
At the inquest, Dr Barber, a consultant neurologist at Frimley Park, said in a statement: “Mr Petto was not doing well at home, he had been struggling to swallow for some time.
"On July 24 he fell in the bathroom and suffered a blow to the head and right leg, from that point onwards he started to feel better.
"On July 26 he began to feel unwell and remained on antibiotics.”
Dr Barber said that by August 13, Mr Petto’s state of health was "pretty stable" and plans were later made for his discharge from hospital.
He was reviewed by staff at 7.30pm on August 23 but fell again 20 minutes later and began bleeding from his right ear.
A CT scan suggested he suffered a haemorrhage and it was concluded the best way forward would be to switch off his ventilator and he died at 5.10pm the following day.
A post-mortem examination showed the cause of death as bronchopneumonia, traumatic intracranial haemorrhage and a fractured skull.
Martin Fleming, assistant coroner for Surrey, recorded a narrative verdict.
He said there had been opportunities to reduce the number of falls Mr Petto had while he was in hospital, that he did have a history of falls and he was satisfied the correct systems were now in place.